India has the world’s second largest urban population (after China). This paper shows the large disparities within this urban population in health-related indicators. It shows the disparities for child and maternal health, provision for health care and housing conditions between the poorest quartile and the rest of the urban population for India and for several of its most populous states. In the poorest quartile of India’s urban population, only 40 per cent of 12 to 23 month-old children were completely immunized in 2004—2005, 54 per cent of under-five year-olds were stunted, 82 per cent did not have access to piped water at home and 53 per cent were not using a sanitary flush or pit toilet.

The paper also shows the large disparities in eight cities between the poorest population (the population in the city that is within the poorest quartile for India’s urban areas), the population living in settlements classified as “slums” and the non-slum population. It also highlights the poor performance in some health-related indicators for the population that is not part of the poorest quartile in several states — for instance in under-five mortality rates, in the proportion of stunted children and in the proportion of households with no piped water supply to their home.

The communities who live in urban informal settlements are diverse, as are their environmental conditions. Characteristics include inadequate access to safe water and sanitation, poor quality of housing, overcrowding, and insecure residential
status. Interventions to improve health should be equity-driven and target those at higher risk, but it is not clear how to prioritise informal settlements for health action.

In implementing a maternal and child health programme in Mumbai, India, we had conducted a detailed vulnerability assessment which, though important, was time-consuming and may have included collection of redundant information. Subsequent data collection allowed us to examine three issues: whether community environmental characteristics were associated with maternal and newborn healthcare and outcomes; whether it was possible to develop a triage scorecard to rank the health vulnerability of informal settlements based on a few rapidly observable characteristics; and whether the scorecard might be useful for future prioritisation.

The City Initiative for Newborn Health documented births in 48 urban slum areas over 2 years. Information was collected on maternal and newborn care and mortality, and also on household and community environment. We selected three outcomes-less than three antenatal care visits, home delivery, and neonatal mortality-and used logistic regression and classification and regression tree analysis to test their association with rapidly observable environmental characteristics.

We developed a simple triage scorecard and tested its utility as a means of assessing maternal and newborn health risk. In analyses on a sample of 10,754 births, we found associations of health vulnerability with inadequate access to water, toilets, and electricity; non-durable housing; hazardous location; and rental tenancy. A simple scorecard based on these had limited sensitivity and positive predictive value, but relatively high specificity and negative predictive value. The scorecard needs further testing in a range of urban contexts, but we intend to use it to identify informal settlements in particular need of family health interventions in a subsequent program.

Mumbai: The downturn and price rise seem to be pushing more people towards poverty in urban areas, especially in Maharashtra, compared to the last financial year. The number of urban poor in the state is expected to go up from 1.31 crore to 1.46 crore by March-end next year, a rise of nearly 15 lakh, or 11.3%, in 2009-10, according to estimates of the Union ministry of housing and urban poverty alleviation.

The rise in urban poverty in the state was negligible in the 2008-09 fiscal compared to 2007-08, according to the ministry’s estimates.

Home to the highest number of urban poor, the state is followed by Uttar Pradesh (1.17 crore), Madhya Pradesh (74.03 lakh), and Tamil Nadu (69.13 lakh). The ministry has projected an 18% growth in urban poverty across India in 2009-10.

The estimates were recently published along with details of funds to be tentatively allocated to the urban poor for self-employment and vocational training.

The estimates have been released at a time when funds to the state for alleviating poverty are being reduced.

Funds under the Swarna Jayanti Shahari Rozgaar Yojna are expected to come down by 10% — the state has been allocated Rs80.75 crore this year.

According to state officials, a majority of urban poor in Maharashtra live in Mumbai. In a recent door-to-door survey conducted by the civic body, more than 10 lakh families in the city had claimed to be living below the poverty line (BPL).

City-based slum activist Simpreet Singh said recession and price rise may have hit those on the brink of poverty. “There are linkages between the formal and the informal sector. The lull in the construction industry, for instance, has hit the livelihood of construction workers, carpenters and electricians,” he said. Price rise has only compounded their woes, putting pressure on their reserves, he said.

Neeraj Hatekar, professor of economics at the Mumbai University, said the unorganised urban sector is the biggest contributor to the poverty pocket. “We lack a system where the urban poor can work themselves out of poverty. The delivery mechanism for poverty alleviation schemes needs to be upgraded,” he said.

Launched in November 2005, ‘Sure Start’ is a five-year project, initiated across UP and Maharashtra

‘Sure Start’, an initiative by Programme for Appropriate Technology in Health (PATH), working to improve maternal and newborn health in Maharashtra, jointly held an urban health meet with the Public Health Department, Government of Maharashtra (GoM). The meet was a result of continuous discussions held between GoM and PATH in the wake of the National Urban Health Mission (NUHM) that is on the anvil and was organised with a view to share ground experiences and learnings till date from the ‘Sure Start’ project.

The participants included senior health officials from the State Government. Public Health Department (PHD), Directorate of Health Services (DHS), State Family Welfare Bureau (SFWB), Municipal Commissioners, Medical Officers of Health (MOH) and RCH officers of all the 22 municipal corporations. Apart from this, with PATH the implementing NGO lead partners of the Sure Start programme also attended the meet.

Launched in November 2005, ‘Sure Start’ is a five-year project, initiated across seven districts of Uttar Pradesh in the rural areas and in select urban slums in seven cities across Maharashtra. The project team has been working with an objective to significantly increase individual, household and community action that directly and indirectly improve maternal and newborn health.

The programme aims at enhancing systems and institutional capabilities for sustained improvement in maternal and newborn care and health status. The team monitors and tracks the progress of interventions in order to assess the progress and success of the program in bringing about the desired behavior change.

Anjali Nayyar, MS Country Director, PATH while welcoming all present at the meet said, “PATH programmes worldwide are based on the key premise that simple practices can have a profound impact on the health status of communities and especially the vulnerable ones. The ‘Sure Start’ programme in UP and Maharashtra will help us learn about implementing strategies to reduce maternal and newborn deaths and improve their health. In the long-run, the project would complement and support the GOI’s commitment to improving maternal and newborn health and nutrition with a special focus on the RCH II and upcoming NUHM.”

In Maharashtra, ‘Sure Start’ supports a range of innovative pilot activities being carried out in urban slums, intended to develop models that may be replicated across cities elsewhere in the future.

There are seven programme models being followed, each of them focus on strengthening the health system and clinical care by working on four key intervention levels. This includes community mobilisation, increasing demand and facilitation of an enabling environment, building household awareness in essential maternal and newborn care and nutrition including recognition of danger signs and appropriate care seeking, appropriate referral, facilitating access to institutional deliveries and skilled attendance at birth and lastly strengthening of linkages between communities and the public and private healthcare systems.

The GoM is looking at ‘Sure Start’ as a model, which will provide key learnings for the upcoming NUHM. Next month the municipal corporation officials from other cities will be visiting ‘Sure Start’ cities and project sites to have an on ground experience of the work being done in these areas. PATH has also been invited by GoM to be a part of the task force on urban health in the state.